Early Versus Late Motion Following Volar Plating of Distal Radius Fractures

Abstract

Background: Distal radius fractures are common, and the trend in fixation has included the use of locked volar plating. The duration of splinting required after surgery and the effect splinting has upon outcome of the wrist are not clear. Our aim was to compare outcome of patients treated with early versus late motion protocol after volar plating. Methods: Thirty-three patients with distal radius fractures were prospectively and randomly enrolled into an early versus late motion study including volar plating of the distal radius fracture. Early motion included an active and passive wrist motion protocol by 14 days after surgery and delayed motion was initiated at 5 weeks. Fractures were defined as intra-articular and extra-articular, and those with, and without, ulnar styloid fracture. Motion and outcome scores (Disabilities of the Arm, Shoulder and Hand [DASH]/patient-rated wrist evaluation [PRWE]), and strength were measured through 1 year. Results: Wrist motion, DASH, and PRWE scores were only significantly different at 6 weeks with no significant differences at any later time points up to 1 year. One patient had complex regional pain syndrome (CRPS) and one had adhesive capsulitis in the late motion group. Conclusions: Following locked volar plating of distal radius fractures, early motion favored earlier return of motion along with lower DASH, PRWE, and pain scores within first 6 weeks. Although the late motion group had delayed recovery, there were no long-term significant differences in motion, strength, outcome, or pain scores. The 2 cases with complications (CRPS and adhesive capsulitis) did occur in the late motion group and may implicate late motion with these problems.

Introduction

Distal radius fractures are very common, and the recent trend in fixation has included the use of locked volar plates.^{1,2,7-9,12,13-15,17} The benefits of stable internal fixation include early range of motion (ROM) for the forearm, fingers, and wrist, and the hopeful return to activities of daily living as soon as the patient is comfortable.

There are many reports that indicate that we can expect good outcomes following locked volar plating^{3,4,6-9,12,15,17} for distal radius fractures as long as we can limit the usual complications related to hardware position and malunion.^5,14 The use of volar plates has increased dramatically² in the last few years, but there has not been much reported regarding the duration of splinting after surgery.

The duration of splinting that is required for comfort or additional stability after locked volar plating and the effect that splinting has upon the outcome of the wrist have only had limited investigation.⁶ Lozano-Calderon et al examined the differences of initiating motion at 2 weeks versus 6 weeks and found no differences between the groups at 3 and 6 months after surgery, although improvement in grip and motion was seen in both groups over time.⁶ They did not evaluate the groups before 3 months after surgery to understand any earlier differences that may exist and also did not follow patients out to 1 year.

Valdes¹⁶ reported that patients who had begun therapy later after volar plating tended to require a longer period of time and more therapy visits to achieve functional ROM, and found that this difference was seen in the first 1 to 2 months following surgery.¹⁶

We have found that most of our patients benefit from early immobilization as it helps limit pain after surgery. We were uncertain whether a longer period of immobilization (>2 weeks) would be associated with more stiffness and worse outcome scores within the first 6 weeks and throughout the first year as well. Our goal was to compare the outcome (strength, motion and outcome and pain scores) of patients treated with an early versus late motion protocol after locked volar plating for their distal radius fracture. In particular, we wanted to closely examine the first 3 months following surgery. Funding for this study was received from DePuy, Inc, to support research study costs only.

Methods

Patient Data

Thirty-three adult patients with unilateral distal radius fractures were prospectively and randomly enrolled into an institutional review board–approved early motion versus late motion study prior to locked volar plating of their distal radius fracture. Enrollment occurred between January 2007 and February 2009. Patients were excluded if they had a previous distal radius fracture, diabetes or other metabolic disorders, arterial or nerve injury, or an open fracture, or were undergoing chemotherapy or radiation therapy. Radius fractures also had to be without extension into the diaphysis and distal ulna fractures were limited to ulnar styloid fractures only (no ulnar head fractures) for inclusion within the study.

There were 39 patients initially enrolled, and 6 patients either dropped out or required removal from the study due to surgical treatment beyond the surgical protocol. Thirty-three patients had sufficient data for calculations and comparisons. The mean age of the entire study population was 54.1 years (SD = 16.5 years). The early motion group included 18 patients with a mean age of 54.9 years (SD = 18.4 years), and the late motion group included 15 patients with a mean age of 53.1 years (SD = 14.6 years). There were 31 female and 2 male patients. There were 17 females and 1 male in the early motion group and 14 females and 1 male in the late motion group.

Randomization occurred before surgery and did include stratification of fracture types although no attempt was made to enroll equal numbers of patients within each stratum. Separate strata were created for intra-articular and extra-articular distal radius fractures and also for the presence or absence of an ulnar styloid fracture. Randomization was then completed with a computerized dynamic allocation program. There was no blinding during this study.

Power Analysis

The primary research outcome was considered to be wrist ROM. We estimated that based upon previous reports¹⁷ following volar plating for distal radius fractures, the SD would be 15.0°, 15.0°, 7.5°, and 16.3° for wrist flexion, extension, pronation, and supination, respectively. Assuming similar variability within a sample population of 100 fractures in each of the 2 groups, we would have a power of 80% to detect differences of 6°, 6°, 3°, and 6.5° (flexion, extension, pronation, supination) between the early and late motion groups (P = .05). Based upon this expected sample size, we allotted 2 years for enrollment and our enrollment period was limited to 2 years by funding for the study.

Statistical Analysis

The statistical analysis focused on comparing the study outcomes between the early motion group and the delayed motion group. The outcomes analyzed included functional parameters—motion (flexion-extension, radial-ulnar deviation, pronation-supination) and strength (kg) (grip strength, appositional pinch strength [APS]) and oppositional pinch strength [OPS]); Disabilities of the Arm, Shoulder and Hand (DASH); patient-rated wrist evaluation (PRWE); and pain visual analog scale (VAS). Separate between-group comparisons were performed at each follow-up time point beginning at 6 weeks. Outcome and pain scores were also compared at 2 weeks.

Continuous variables were compared between the early motion group and the late motion group using Wilcoxon rank sum tests, and categorical variables were compared using chi-square tests. P values less than .05 were considered statistically significant.

Fracture Classification

Distal radius fractures were defined as intra-articular and extra-articular. Distal ulna injuries were described as those with or without an ulnar styloid fracture. Operative indications for distal radius fractures included significant radial shortening (>3 mm), extension (beyond neutral), loss of radial inclination (>5°), and articular incongruity or instability (Table 1).

Table 1.

Distal Radius Fracture and Ulnar Styloid Fracture Distribution.

	Early motion		Late motion
	Distal radius fracture	Ulnar styloid fracture	Distal radius fracture	Ulnar styloid fracture
	12 extra-articular	6	10 extra-articular	5
	6 intra-articular	4	5 intra-articular	4
Total	18	10	15	9

Surgical Technique

Volar plating was completed through a flexor carpi radialis¹¹ approach with repair of the pronator quadratus. A brachioradialis tenotomy was used when required to facilitate reduction.¹⁰ Cancellous allograft was used commonly. If a displaced ulnar styloid fracture had associated distal radioulnar joint instability after reduction and fixation of the radius fracture, tension band fixation of the ulnar styloid was the technique agreed upon for the surgical protocol. Postoperatively, a dressing with a wrist splint was applied in all cases.

Postoperative Protocols and Measurements

Early motion was defined as initiation of an active and passive wrist motion protocol by 14 days after surgery. Delayed wrist motion was initiated at 5 weeks while finger, elbow, and shoulder motion were allowed and encouraged within the wrist splint or short arm cast as in the early motion group. Both protocols recommended home therapy 3 to 4 times daily with 10 repetitions at each session. All patients had supervised therapy with a certified hand therapist at least at all clinic visits and were instructed in a home exercise program as well.

Early ROM Protocol

• Day 1-14: finger and thumb ROM in wrist splint through 14 days

• Progression to active range of motion (AROM), active-assisted range of motion (AAROM) and passive range of motion (PROM) and gradual strengthening

• Wrist flexion-extension; radioulnar deviation; pronation-supination

Delayed ROM Protocol

• Day 1-14 finger and thumb ROM in splint

• Wrist splint or short arm cast until week 5

• Progression to AROM, AAROM and PROM and strengthening

• Wrist flexion-extension; radioulnar deviation; pronation-supination

Motion (flexion-extension, radial-ulnar deviation, pronation-supination) and strength (kg) (grip strength, APS, and OPS), DASH, PRWE, and pain VAS were measured at 2, 4, 6, 8, 10, 12, 26, and 52 weeks for the early motion group. The patients were allowed a window of ±3 days to be included within the data time frame. For the late motion group, the only difference was that we obtained measurements at 5 weeks instead of 4 weeks. All strength measurements were reported as the mean of 3 attempts (Jamar Grip Dynamometer).

Radiographs were reviewed (PA, oblique, tilt lateral) postoperatively at 2 weeks, 6 weeks, 3 months, and 12 months. Fracture healing and fracture alignment and implant position were evaluated for collapse or displacement.

Results

Wrist motion and DASH, PRWE, and pain VAS scores were all significantly different at 6 weeks. Results are listed in Table 2 for significant results. The mean-value results are listed below (Table 3) for ROM, strength, outcome score, and pain score for each measured time point after surgery.

Table 2.

Significant Results at 6 Weeks.

Motion	Early motion	Late motion	P value
Flexion/extension	83 (15) n = 15	66 (12) n = 13	P = .004
Pronation/supination	144 (20) n = 15	108 (24) n = 13	P = .001
Ulnar/radial deviation	39 (7.5) n = 15	25 (17) n = 13	P = .001
DASH, PRWE, and Pain VAS	Early motion	Late motion	P value
DASH (6 weeks)	38 (24) n = 15	52 (13) n = 13	P = .034
PRWE (6 weeks)	30 (24) n = 16	50 (11) n = 13	P = .005
Pain VAS	0.8 (1.1) n = 16	1.5 (1.5) n = 13	P = .034

Note. DASH = Disabilities of the Arm, Shoulder and Hand; PRWE = patient-rated wrist evaluation; VAS = visual analog scale.

Table 3.

Summary: Results (Means).

	Motion protocol	Flexion/extension	Pronation/supination	Radio-ulnar deviation	Grip (kg)	APS (kg)	OPS (kg)	DASH	PRWE	VAS
2 weeks	Early	—	—	—	—	—	—	59	55	2.1
	Late	—	—	—	—	—	—	73	66	1.9
6 weeks	Early	83	144	39	11	4.5	4.0	38	30	0.8
	Late	66	108	25	6	3.7	3.2	52	50	1.5
8 weeks	Early	93	152	44	14	4.5	4.2	24	21	0.6
	Late	86	153	41	14	4.6	4.4	24	26	0.4
10 weeks	Early	102	166	46	15	5.3	5.1	20	13	0.5
	Late	91	158	40	14	4.7	4.6	20	19	0.4
12 weeks	Early	102	163	44	18	5.6	5.4	16	13	0.3
	Late	100	159	44	17	6.2	5.1	12	11	0.9
26 weeks	Early	120	172	53	21	5.8	6.1	12	8.2	0.2
	Late	119	165	47	22	7.9	7.7	4.5	5.4	0.1
52 weeks	Early	122	172	53	23	5.4	6.0	6.0	5.4	0.1
	Late	122	171	56	21	5.4	6.0	5.3	5.1	0.0

Note. APS = appositional pinch strength; OPS = oppositional pinch strength; DASH = Disabilities of the Arm, Shoulder and Hand; PRWE = patient-rated wrist evaluation; VAS = visual analog scale.

There were also significant differences between the APS and OPS at 10 weeks when comparing the involved wrist with the uninvolved wrist, APS (P = .027), OPS (P = .040), although there was no significant difference between the APS and OPS measurements of the involved wrists between groups. There were no significant differences at any later time points up to 1 year.

All of the distal radius fractures healed and there were no malunions or hardware problems. There were no cases that required open reduction and internal fixation of the ulnar styloid. There were no cases that required revision surgery for collapse or hardware removal.

Complications

There were 7 patients who developed some carpal tunnel symptoms after surgery. None of these patients required carpal tunnel release within the first year after surgery and all were treated with splinting or corticosteroid injections. There was 1 patient who was initially enrolled within the study but dropped out immediately from the study who did have a carpal tunnel release at the time of fracture fixation. Of the 7 patients with carpal tunnel syndrome (CTS), 4 were in the early and 3 were in the late motion group. One patient had bilateral symptoms.

There was one case of ipsilateral adhesive capsulitis of the shoulder in the late motion group, which resolved with physical therapy. There was also one patient with a complex regional pain syndrome (CRPS), who was also in the late motion group, who was treated with sympathetic blockade, physical therapy, and Neurontin with good resolution of symptoms. One patient with CTS also developed a trigger finger that was also treated conservatively. There were no infections.

Discussion

Our results indicate that the patients who began motion at 2 weeks reached their motion, strength, and improved outcome scores several weeks earlier than the group that began motion at 5 weeks. Patients in both groups continued to improve with motion, strength, and outcome scores through the first year after surgery. These results are similar to Lozano-Calderon et al⁶ in that we also found no significant differences at any time after 3 months through 1 year. We did find an early difference in motion as Valdes¹⁶ suggested, but this was limited to the 6-week comparison. These results suggest that patients and surgeons may expect similar ultimate motion, strength, and outcome scores if wrist splinting is continued up to 5 weeks after locked volar plating. At 10 weeks, there was a significant difference in pinch strength, but this was only seen when comparing the pinch strength as a percentage with the uninvolved side, not upon direct comparison between the injured wrists. Although this was a significant finding, it likely represents a very small clinical difference.

Radiographically, we did not observe any obvious differences such as earlier or later healing, although this was not a focal point of our investigation. All fractures united and we did not find any fractures that had significant collapse after fixation.

Although it is obvious that there will be a difference between these 2 groups at about 6 weeks when the early motion group has been moving and the late motion group is just getting out of their casts, we report this significant difference at that time because it was the only significant difference that existed throughout the first year after surgery. The clinical relevance of these findings includes the following: (1) the early motion group did achieve equal or better pain control, outcome score, and motion, and achieved these results several weeks earlier than the delayed group; and (2) there was no difference in outcome when comparing the groups out to 1 year.

Therefore, early motion (starting at 2 weeks) is favorable and may allow earlier recovery and return to activities and limit the period of recovery from this common injury.

Although the power of our study was limited, we did find that the one case of adhesive capsulitis and the one case of CRPS did only occur in the late motion group. Although this finding was not statistically significant, it does remind us of the relationship of delayed motion and these well know complications and provides support for early motion after volar plating.

Although we had relatively few complications, certainly with longer follow-up time we may discover complications related to the plates as is well described in the literature.^5,14

Our study had several limitations. We had fewer patients than would be ideal regarding power. Our sample size was small and had limited power compared with our initial expectations regarding patient enrollment, and our funding limited the study to 2 years for enrollment and we stopped enrolling at that point. Our smaller sample size lowered our power and limited the ability to detect differences between the groups.

We used a broad grouping of extra-articular versus intra-articular distal radius fractures. This limitation was accepted as we did not have enough patients or fractures to consider any subgroup comparison between extra-articular, partial articular, and complete articular injuries. Therefore, we accepted the random (but stratified) distribution of our simple fracture classification.

While we had data on 33 patients, there were many calculations that were made using a pool (range n = 23-29 patients) of data points as not every patient had all data for each time point. These variations were accounted for in considering for significance.

We also had a predominance of female patients, and this may have introduced bias into our results. However, as distal radius fractures are more common in females, our findings would be expected to remain valid especially for female patients. Although these limitations are not ideal, we feel that the prospective randomized manner that we evaluated these patients for their “common” fracture patterns likely reflects the outcome of these common fracture types with their respective postoperative motion protocol.

In summary, following locked volar plating of distal radius fractures, early motion favored earlier return of wrist motion along with lower DASH, PRWE, and pain scores within the first 6 weeks. Although the late motion group had delayed recovery, they had no ultimate significant differences in motion, strength, outcome, or pain score. Although we were not able to find a significant association of complications with late motion, the 2 cases with complications (CRPS, adhesive capsulitis) did occur in the late motion group. Therefore, we try to begin wrist motion within 2 weeks from surgery to facilitate recovery and to try and avoid these complications.